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Filed for Record 01/25/2016 04:59:08 PM - Kittitas County, WA Auditor - 201601250079 Page 3 of 4 <br />14. Describe the damages or injuries which you sustained as a result of the incident: <br />15. <br />What is the amount of damages claimed? (Include estimates and bills, if available): <br />16. How did you identify the County as the party responsible for your damage? <br />17 <br />List the names and addresses of all witnesses to the incident: <br />1� /A <br />18. Are you covered by insurance? If yes, who is your insurance agent/carrier? <br />Dated this Day of 20u. <br />Subscribed and sworn (affirmed) to before me this day of 20_ <br />Seal <br />Notary Public in and for the State of Washington <br />Residing at <br />3 of 3 <br />Kittitas County Claim for Damages Form <br />Revised 92012 <br />